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Mouth Cancer: early detection

Aim

To understand the signs, symptoms, and risk factors of mouth cancer for early detection.

Objectives

Discuss the meaning of detecting mouth cancer early

Discuss the signs and symptoms of mouth cancer

Discuss the risk factors of mouth cancer

GDC development outcomes: A, C, D

Introduction

Mouth cancer is rising amongst the UK population. In the past year, a devasting total of 2,702 British people lost their lives to the disease. This type of cancer can develop at numerous sites, including the lips, tongue, salivary glands, floor of mouth, cheeks, sinuses, hard and soft palate, and the pharynx. It is the 14^th most common cancer in the UK. With the 10-year survival rate only ranging between 18%-57%, it is crucial that mouth cancer is detected as soon possible.¹ Early detection is not limited to the time the abnormal growth has been present for, but to its size and whether it has metastasised. If the cancer is less than 2cm in diameter, with no involvement of the lymph nodes and no further metastasis, its detection is classified as being early.² This increases the probability of successful of treatment, thereby reducing mortality. Dentistry is a team profession and the dental nurse s role is pivotal in helping to reduce the number of mouth cancer cases occurring, as well as detecting such pathology. Awareness of signs and symptoms of mouth cancer, its risk factors and provision of oral health promotion advice are fundamental.

Signs and Symptoms

The presentation of mouth cancer can vary. They comprise primarily of abnormal lumps on the head, neck, or in the mouth, red or white patches in the mouth, a hoarse voice, or an ulcer that has remained unhealed for three weeks. When a patient first arrives, it is an opportunity to assess them extra-orally, as well as listen to their concerns. Basal cell carcinoma and melanoma are types of skin cancer and can present as scabs, ulcers, or abnormal pigmentation with irregular borders. Squamous cell carcinoma is the most frequent intraoral malignancy and can present in many ways, one of which is a firm and painless ulcer (Figure 1).³

Figure 1. Squamous cell carcinoma presenting as an ulcer on the tongue ³

If you notice an abnormality, politely inquire about it with the patient and inform the dentist, hygienist, or therapist. It can be photographed, measured, and included in the patient s records. This ensures that your findings are both monitored and managed appropriately. To aid continuity of care, assessment, and support, review appointments can be booked.

Dental nursing involves being positioned differently to the dentist, hygienist, or therapist and therefore views of the patient will vary. The floor of the mouth and the lateral borders of the tongue are sites for mouth cancer to develop. Remaining vigilant whilst retracting the patient s tongue during aspiration can help detect abnormalities. A red patch, known as erythroplakia (Figure 2), has a greater probability of being malignant than a white patch, leukoplakia (Figure 3). A mixture of both red and white patches is called speckled leukoplakia (Figure 4). Notify the dentist of anything you notice to be suspicious.

Figure 2. Erythroplakia in the floor of the mouth ³

Figure 3. Leukoplakia of the tongue ³

Figure 4. Speckled leukoplakia in the floor of the mouth ³

Risk Factors

Tobacco significantly increases the risk of mouth cancer developing, whether it is smoked or chewed. This risk is amplified with consumption of alcohol, as they both contain carcinogens. Smoking suppresses cell mediated immunity and reduces the inflammatory response. The oral mucosa is more permeable with alcohol, therefore there is a greater chance of infection occurring. Amongst some cultures, betel/paan chewing is popular. This involves areca nut and slaked lime wrapped in betel leaf being held in the cheek for long periods of time. A presentation of this habit is limited mouth opening, due to scarring of buccal tissues. This scarring, which is known as oral submucous fibrosis, is susceptible to developing mouth cancer. It is important for the dental nurse to be aware that smoking, alcohol and chewing betel nut are all risk factors of mouth cancer. The more frequent and greater the consumption of these, the larger the risk is. Helping to provide smoking cessation, alcohol intake advice and raising awareness of the harmful effects of betel nut chewing to patients is invaluable.

Smoking cessation consists of asking the patient about their smoking habits and advising them about the harmful effects, primarily the increased risk of mouth cancer. Assessment of their motivation towards stopping smoking should then be carried out. Assistance can include guidance to using counselling services, or information about nicotine gum and patches. There should be an arrangement to follow-up on this. Men and women should be advised not to drink more than 14 units of alcohol per week. In cases of high alcohol intake, support services can be offered or a referral to their general practitioner.

Increasing age and chronic sun exposure are risk factors for the development of mouth cancer and patients should be aware of this. Chronic sun exposure is commonly associated with lip cancer., however the cheeks, nose, outer ears, and scalp are also exposed high risk areas. Informing patients about the damaging effects of long-term sunlight is important.

The Human Papilloma Virus (HPV), in particular variants HPV16 and HPV18 have been associated with oropharyngeal cancer. Therefore, it is worthwhile to raise awareness amongst patients about the HPV vaccine. Genetic makeup can affect development of mouth cancer too and a poor diet leads to nutritional deficiencies, which compromises the immune system. The dental nurse can support in emphasising the value of a balanced and healthy diet to patients.

Poor oral hygiene increases the occurrence of plaque retentive factors, in particular calculus, which can harbour harmful microorganisms. Bacteria, such as Porphyromonas gingivalis and fungi, including Candida albicans, can cause opportunistic infections and increase susceptibility to developing mouth cancer.⁴ Providing oral hygiene advice and reinforcing prevention subsequently helps patients to improve their oral health and reduce risks. This can consist of reminding patients to brush their teeth for at least two minutes, twice daily, with a fluoride containing toothpaste and to use interproximal aids.

Dental Check-ups

The nurse s role is instrumental in helping to calm and relax patients. A positive experience at an appointment means a patient is more likely to return for dental check-ups. Routine examinations are crucial for screening for mouth cancer and detecting it early. The dental nurse can assist in encouraging patients to attend their appointments.

Conclusion

Mouth cancer is a multifactorial disease and can detrimentally affect quality of life. The dental nurse can help educate patients about its appearance, inform them to regularly inspect their mouths and contact a dentist immediately if concerned about anything they discover. Often premalignant abnormalities are asymptomatic. A delay in seeking help can be damaging to health. The success of treatment is reduced if the cancer is greater than 2cm in diameter, with lymph node involvement and distant metastasis. Alerting patients to the risk factors of mouth cancer and ways to reduce them are positive tools. A proactive approach is fundamental for effectively helping patients. The dental nurse has a vital role in raising awareness about mouth cancer and helping to detect it early.

Further Information

Visit the Mouth Cancer Foundation website https://www.mouthcancerfoundation.org/

Visit the Macmillan Cancer Support website https://www.macmillan.org.uk/cancer-information-and-support/head-and-neck-cancer/mouth-cancer

References

1.) Oral Health Foundation, 2021. The State of Mouth Cancer UK Report 2020/21. [online] pp.1-25. Available at: [Accessed 3 January 2021].

2.) Lewis, M., 2018. Mouth cancer: presentation, detection and referral in primary dental care. British Dental Journal, 225(9), pp.833-840.

3.) Courtesy of Professor M A O Lewis.

Mathur, R. et al., 2018. Role of Poor Oral Hygiene in Causation of Oral Cancer a Review of Literature. Indian Journal of Surgica